Background: Nasal bone fractures are the commonest type of the bony
facial injuries seen in emergency department. The objectives of the
present study were to determine the age and gender distribution etiology
symptoms signs and complications of simple nasal bone fractures and
complications of their closed reduction.

Material and Methods: This cross-sectional study was conducted at
Departments of ENT Mardan Medical Complex Mardan and MMM Teaching
Hospital D.I.Khan Pakistan from July 2012 to Jun 2013. All patients with
simple nasal bone fracture of any age and gender were included. All
patients were treated by closed reduction. Data regarding gender age in
years age grouping etiology symptoms signs and complications were
analyzed as frequency and percentage.

Results: A total of 120 patients with simple nasal bone fractures
were included in the study. Males 90 (75%) out-numbered females 30 (25%)
with a ratio of 3:1. The mean age of the patients was 20.6614.86 (2-60)
with a range of 58 years. The most frequent etiology symptom sign and
complication was road traffic accident in 65 (54.15%) epistaxis in 85
(70.80%) external nasal deformity in 92 (76.65%) and septal hematoma in
24 (20%) cases respectively. Persistent postoperative nasal deviation
was a complication in seven (5.80%) patients with closed reduction.

Conclusion: Road traffic accident is the most common cause of nasal
trauma. Closed reduction for simple nasal bone fracture generally
produces acceptable cosmetic results. By knowing the etiology of nasal
trauma the risk of nasal injuries can be reduced by taking safety
measures and precautions.

Key words: Traffic Accidents; Epistaxis; Nasal Obstruction;
Etiology.

Introduction

Being the most prominent and projected in position nose is
frequently injured facial structure accounting for approximately 39 % of
all bony injuries in facial trauma1 and the third most frequent of all
body fractures.12 Road traffic accidents sports injuries interpersonal
violence falls and blast injuries all contribute to nasal trauma.3

Nasal trauma commonly presents with epistaxis external nasal
deformity periorbital ecchymosis nasal obstruction and pain.4 It can
involve all age groups from pediatrics to adults. Adults are
predominantly affected with male to female ratio of 2:1.15 In pediatric
age group intrauterine forces forceps delivery breech presentation all
contribute to nasal trauma. The low face to head volume ratio and
protected environment parental supervision are responsible for less
nasal trauma in this group.5

Male adults being more involved in occupational trauma violence
road traffic accidents falls and sports injuries receive more nasal
trauma.6 Nasal bone fractures may occur as simple nasal fracture or
associated with other facial injuries like maxillary zygomatic and other
mid-face comminuted fractures.7

Simple nasal bone fractures can be diagnosed easily with history
and clinical examination however certain radiological studies like x-ray
nasal bone lateral view CT of nose and sinuses can help to assess the
type and severity of injury and other associated fractures.6

Simple nasal bone fractures can be treated by two methods. One is
closed reduction of fragments with digital manipulation or use of
Walshlam and Asch forceps. The other method is open reduction.8

The objectives of the present study were to determine the age and
gender distribution etiology symptoms signs and complications of simple
nasal bone fractures and complications of closed reduction for simple
nasal bone fractures.

MATERIAL AND METHODS

This cross-sectional study was conducted at the Departments of ENT
Mardan Medical Complex Mardan and Mufti Mehmood Memorial Teaching
Hospital D.I.Khan Pakistan from July 2012 to Jun 2013.

An approval from the Ethical Committee of the Hospital was
obtained. A written informed consent containing terms about the
inclusion in study benefits and risks involved was obtained from each
patient.

All patients with simple nasal bone fracture (not associated with
fractures of other facial bones) were included. Patients with associated
head and neck injuries were excluded. Patients already treated at other
centers and referred for further treatment were also excluded from the
study. Patients were admitted in ENT ward through emergency or
outpatient departments. A thorough history was taken and detailed
oto-rhinological as well as general physical examination was carried
out. Digital x-ray nose lateral view was done in all cases. Relevant
investigations for general anaesthesia were carried out. All findings
were recorded on a designed proforma.

All patients were treated by closed reduction using Walshalam and
Ache's forceps under general anaesthesia. After manipulating the
fractured fragments Plaster of Paris was applied over the nose for
stabilization of the nasal skeleton for 7 days in every case. Internal
fixation was done by placing anterior nasal packing for 72 hours and
plastic splints for one week. Those patients having swelling of the nose
at the time of presentation reduction was deferred till the edema got
subsided. Postoperatively patients were followed for 6 weeks to see for
any persistent deviation of the nose. Those patients who continued to
suffer from significant nasal deviation were offered septo-rhinoplasty
after 6 months in adult patients and pediatric cases were advised to do
it later by the age of 18 years.

Gender age (numerical data) in years and age grouping were
demographic variables. Etiology symptoms signs and complications of
simple nasal bone fracture and complications of closed reduction were
research variables. All variables except age were categorical data. The
categorical data was analyzed as frequencies and percentages while
numerical data (age in years) was analyzes as mean SD minimum maximum
and range. As per protocol of the study no further analysis of data and
no test of significance were required. Age grouping was as; 02-10 11-20
21-30 31-40 41-50 more than 50 years.

RESULTS

A total of 120 patients with simple nasal bone fracture were
included in the study. Males 90 (75%) out-numbered females 30 (25%) with
a ratio of 3:1. The mean age of the patients was 20.6614.86 (260) with a
range of 58 years. The age grouping of the patients is given in Table 1.

Road traffic accidents was the most common etiology with 65
(54.15%) cases followed by sports injuries with 24 (20%) patients
violence in 22 (18.35%) patients and blast injuries in nine (7.50%)
patients.

The symptoms were epistaxis in 85 (70.80%) nasal obstruction in 45
(37.50%) and headache in 30 (25%) cases. The signs were external nasal
deformity with periorbital ecchymosis in 92 (76.65%) feeling of crepitus
between bone fragments in 88 (73.30%) and swollen nasal bridge in 65
(54.15%) cases. Septal hematoma in 24 (20%) and septal abscess in six
(5%) were complications of simple nasal bone fractures. Persistent
postoperative nasal deviation was a complication in seven (5.80%)
patients with closed reduction for simple nasal bone fractures.

DISCUSSION

Nose is located prominently in the face and it is its prominent
location that it suffers trauma on many occasions. Several different
causes have been reported in literature like road traffic accidents
interpersonal violence sports injuries and falls. Much controversy
exists as to the ideal treatment to properly address acute nasal
fractures. A successful management algorithm should provide each patient
with an aesthetically and functionally acceptable nose.

Majority of the patients in the present study were in the second
decade of their life. Almost similar results were also reported in a
local study by Afshin in which age of the patients ranged between 10-70
years.112 In another study by Cannon CR14 the commonest age group
affected was 11-20 years. Contrary to these reports in another study13
the age group mostly involved was 21-40 years. While results of Yilmiz17
showed that the maximum number of patients (68.75 %) was in pediatric
age group.

Males receive more nasal trauma as compared to females probably due
to more involvement in physical activities. In our series males were
more affected i.e in 90 cases as compared to females in 30 cases with a
ratio of 3:1. This is in accordance with other studies.1115 Sang HK5
also reported a male preponderance over females with a ratio of 5.7:1 in
his series of 741 patients. Yakup C13 reported a male to female ratio of
4:1. Javad Rashid6 found 31 males with 9 females in his series of 40
patients. In Afshin Muhammad1 study the male to female ratio was 2:1.
Nardis15 reported male to female ratio of 1.8:1.

Road traffic accident was the most frequent cause of nasal trauma
in our study. This may be due to young drivers with over speeding no
licensing and not observance of traffic rules. Smith H4 reported motor
vehicle crash as the most common cause for nasal trauma in 47% of
patients. Interpersonal violence was the next common reason for nasal
trauma in our study which is probably due to lack of tolerance anxiety
and other psychological reasons in the terrorism affected area. Sang HK5
found interpersonal violence in 38% of his series followed by fallings
in 31% and sports injuries in 17% of cases. Yakup C13 also reported
violence as the most frequent cause of nasal trauma in his series in 60%
cases fallings in 30% cases accidents in 4.5% cases and sports injuries
in 4.5% cases in his study on pure nasal fractures.

The symptoms in descending order of frequency were nasal
obstruction epistaxis and headache in patients with simple nasal bone
fractures as supported by findings of the other studies.1516

Nasal obstruction was probably due to edema and associated
complication like septal hematoma.

Septal hematoma was the most common complication of nasal trauma in
our study as also reported in literature.7911 The picture of septal
hematoma is emerged when a patient with nasal trauma develops bilateral
nasal obstruction and open mouth breathing during sleep especially in
children.

In our study all patients were treated by closed reduction.
Tremendous satisfaction with closed reduction has been reported in
literature with this mode of treatment for simple nasal bone
fractures.1718 In our series 5.8% of the patients complained of
persistent nasal deviation. Contrary to our results the post-reduction
incidence of nasal deformities have been shown to be as high as 40% to
62% independent of the surgeon's experience when simple closed
manipulation was employed.1920 Our better results

could be due to either more adequate reduction of the fracture or
complete management of a component of the fracture at the time of the
treatment.

Family physicians as well as public at large should be made aware
of the seriousness of nasal trauma as this accounts for a high rate of
morbidity in our country. Our study is limited by a rather small sample
size.

CONCLUSIONS

Road traffic accident is the most common cause of nasal trauma.
Closed reduction for simple nasal bone fracture generally produces
acceptable cosmetic results. By knowing the etiology of nasal trauma the
risk of nasal injuries can be reduced by taking safety measures and
precautions.